Interdisciplinary Decision Making in Hemorrhagic Stroke Based on CT Imaging—Differences Between Neurologists and Neurosurgeons Regarding Estimation of Patients' Symptoms, Glasgow Coma Scale, and National Institutes of Health Stroke Scale

Background and Purpose: Acute intracerebral hemorrhage (ICH) requires rapid decision making toward neurosurgery or conservative neurological stroke unit treatment. In a previous study, we found overestimation of clinical symptoms when clinicians rely mainly on cerebral computed tomography (cCT) analysis. The current study investigates differences between neurologists and neurosurgeons estimating specific scores and clinical symptoms. Methods: Overall, 14 neurologists and 15 neurosurgeons provided clinical estimates and National Institutes of Health Stroke Scale (NIHSS) as well as Glasgow Coma Scale (GCS) based on cCT images and basic information of 50 patients with hypertensive and lobar ICH. Subgroup analyses were performed for the different professions (neurologists vs. neurosurgeons) and bleeding subtypes (typical location vs. atypical). The differences between the actual GCS and NIHSS scores and the cCT-imaging-based estimated scores were depicted as Bland-Altman plots and negative and positive predictive value (NPV and PPV) for prediction of clinical relevant items. Delta NIHSS points (Delta GCS points) were calculated as the difference between actual and rated NIHSS (GCS) including 95% confidence interval (CI). Results: Mean Delta GCS points for neurosurgeons was 1.16 (95% CI: -2.67-4.98); for neurologists, 0.99 (95% CI: -2.58-4.55), p = 0.308; mean Delta NIHSS points for neurosurgeons was -2.95 (95% CI: -12.71-6.82); for neurologists, -0.33 (95% CI: -9.60-8.94), p < 0.001. NPV and PPV for stroke symptoms were low, with large differences between different symptoms, bleeding subtypes, and professions. Both professions had more problems in proper rating of specific clinic-neurological symptoms than rating scores. Conclusion: Our results stress the need for joint decision making based on detailed neurological examination and neuroimaging findings also in telemedicine

Romosozumab (sclerostin monoclonal antibody) versus teriparatide in postmenopausal women with osteoporosis transitioning from oral bisphosphonate therapy : a randomised, open-label, phase 3 trial

Background: Previous bisphosphonate treatment attenuates the bone-forming effect of teriparatide. We compared the effects of 12 months of romosozumab (AMG 785), a sclerostin monoclonal antibody, versus teriparatide on bone mineral density (BMD) in women with postmenopausal osteoporosis transitioning from bisphosphonate therapy. Methods: This randomised, phase 3, open-label, active-controlled study was done at 46 sites in North America, Latin America, and Europe. We enrolled women (aged >= 55 to <= 90 years) with postmenopausal osteoporosis who had taken an oral bisphosphonate for at least 3 years before screening and alendronate the year before screening; an areal BMD T score of -2.5 or lower at the total hip, femoral neck, or lumbar spine; and a history of fracture. Patients were randomly assigned (1:1) via an interactive voice response system to receive subcutaneous romosozumab (210 mg once monthly) or subcutaneous teriparatide (20 mu g once daily). The primary endpoint was percentage change from baseline in areal BMD by dual-energy x-ray absorptiometry at the total hip through month 12 (mean of months 6 and 12), which used a linear mixed effects model for repeated measures and represented the mean treatment effect at months 6 and 12. All randomised patients with a baseline measurement and at least one post-baseline measurement were included in the efficacy analysis. This trial is registered with ClinicalTrials.gov, number NCT01796301. Findings: Between Jan 31, 2013, and April 29, 2014, 436 patients were randomly assigned to romosozumab (n=218) or teriparatide (n=218). 206 patients in the romosozumab group and 209 in the teriparatide group were included in the primary efficacy analysis. Through 12 months, the mean percentage change from baseline in total hip areal BMD was 2.6% (95% CI 2.2 to 3.0) in the romosozumab group and -0.6% (-1.0 to -0.2) in the teriparatide group; difference 3.2% (95% CI 2.7 to 3.8; p<0.0001). The frequency of adverse events was generally balanced between treatment groups. The most frequently reported adverse events were nasopharyngitis (28 [13%] of 218 in the romosozumab group vs 22 [10%] of 214 in the teriparatide group), hypercalcaemia (two [<1%] vs 22 [10%]), and arthralgia (22 [10%] vs 13 [6%]). Serious adverse events were reported in 17 (8%) patients on romosozumab and in 23 (11%) on teriparatide; none were judged treatment related. There were six (3%) patients in the romosozumab group compared with 12 (6%) in the teriparatide group with adverse events leading to investigational product withdrawal. Interpretation: Transition to a bone-forming agent is common practice in patients treated with bisphosphonates, such as those who fracture while on therapy. In such patients, romosozumab led to gains in hip BMD that were not observed with teriparatide. These data could inform clinical decisions for patients at high risk of fracture

Romosozumab Enhances Vertebral Bone Structure in Women With Low Bone Density.

Funder: NIHR Cambridge BRC; Id: http://dx.doi.org/10.13039/501100018956Romosozumab monoclonal antibody treatment works by binding sclerostin and causing rapid stimulation of bone formation while decreasing bone resorption. The location and local magnitude of vertebral bone accrual by romosozumab and how it compares to teriparatide remains to be investigated. Here we analyzed the data from a study collecting lumbar computed tomography (CT) spine scans at enrollment and 12 months post-treatment with romosozumab (210 mg sc monthly, n = 17), open-label daily teriparatide (20 μg sc, n = 19), or placebo (sc monthly, n = 20). For each of the 56 women, cortical thickness (Ct.Th), endocortical thickness (Ec.Th), cortical bone mineral density (Ct.bone mineral density (BMD)), cancellous BMD (Cn.BMD), and cortical mass surface density (CMSD) were measured across the first lumbar vertebral surface. In addition, color maps of the changes in the lumbar vertebrae structure were statistically analyzed and then visualized on the bone surface. At 12 months, romosozumab improved all parameters significantly over placebo and resulted in a mean vertebral Ct.Th increase of 10.3% versus 4.3% for teriparatide, an Ec.Th increase of 137.6% versus 47.5% for teriparatide, a Ct.BMD increase of 2.1% versus a -0.1% decrease for teriparatide, and a CMSD increase of 12.4% versus 3.8% for teriparatide. For all these measurements, the differences between romosozumab and teriparatide were statistically significant (p < 0.05). There was no significant difference between the romosozumab-associated Cn.BMD gains of 22.2% versus 18.1% for teriparatide, but both were significantly greater compared with the change in the placebo group (-4.6%, p < 0.05). Cortical maps showed the topographical locations of the increase in bone in fracture-prone areas of the vertebral shell, walls, and endplates. This study confirms widespread vertebral bone accrual with romosozumab or teriparatide treatment and provides new insights into how the rapid prevention of vertebral fractures is achieved in women with osteoporosis using these anabolic agents. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).This research was funded by Amgen and supported by the NIHR Cambridge BRC. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care

The dispute over the insurance of the "laufendes Geschirr" ("current harness") in the development of fire insurance in Württemberg

Das geltende Versicherungsrecht steht nicht gerade im Zentrum akademisch gepflegter Rechtswissenschaft. Erst recht ist die Geschichte des Versicherungsrechts eine Randerscheinung. Das wird der gesellschaftlichen und wirtschaftlichen Bedeutung der Versicherung in den Jahrhunderten nach ihrem Aufkommen nicht gerecht. Daher hält der Autor es für lohnenswert, Dokumente aus dem Stuttgarter Staatsarchiv zum Streit über die Zugehörigkeit des „laufenden Geschirrs“ zur Monopolgebäudebrandversicherung der wissenschaftlichen Öffentlichkeit genauer bekannt zu machen. Die Quellen wurden schon von Paul Sauer in seiner Darstellung von zweihundert Jahren Württembergischer Gebäudebrandversicherung aus dem Jahre 1973 erwähnt. Die Dokumente schildern zwei Leitfälle zum Problem der Grenzziehung zwischen staatlicher Immobiliar- und privater Mobiliarversicherung. Dieser Streit hat beispielhafte Bedeutung für die Deckungsbreite verschiedener Versicherungssparten, die Prämienkalkulation und das versicherungsrechtliche Phänomen der Risikoausschlüsse im Allgemeinen. Die Berechtigung, sich mit diesem Thema zu befassen, ergibt sich aber auch daraus, zu verstehen, wie der Staat – nicht unbedingt auf die Zeit des Kameralismus beschränkt – durch Teilnahme am Wirtschaftsverkehr seinen Aufgaben zur Daseinsvorsorge nachkommt. Die Arbeit enthält einen Anhang, der fast so umfangreich ist wie der Textteil. Der Anhang dient nicht nur als Beleg der historisch-juristischen Darstellung, sondern als Quellenedition. In diesen Quellen geht es um den Umgang mit der Versicherung des „laufenden Geschirrs“ in zwei praktischen Fällen. Im einen Fall (Gaismayer) ging es um die Einrichtung einer Mühle, im anderen (Fürgang) um die Maschinen einer Spinnerei. Im ersten Fall entschied der König relativ schnell zugunsten des Beschwerdeführers, der durch fehlerhaftes Verhalten des Ortsvorstehers als Vertreter der Gebäudebrandversicherungsanstalt eine verbotene Doppelversicherung abgeschlossen hatte. Im anderen Fall, der viel umfangreichere Akten umfasst, erhielt der Beschwerdeführer auch durch königliche „Gnade“ die ihm vorenthaltene Versicherungsleistung. Davor und danach haben die verschiedensten Behörden und Sachverständigen zu dem Fall Stellung genommen, was eine klärenden Verfügung des Innenministeriums im Jahr 1843 notwendig machte. Vor der Darstellung der beiden Fälle wird in einem umfangreichen Einleitungskapitel die Entwicklung der Feuerversicherung in Württemberg dargestellt. Bis es zur wirtschaftspolitischen Aktivität des Herzogtums im 18. Jahrhundert kam, war eine lange Entwicklungszeit zu durchlaufen. In der Arbeit werden Ansätze des Versicherungswesens in anderen europäischen und deutschen Ländern dargestellt und zur Entwicklung in Württemberg in Beziehung gesetzt. Dabei wird zusammengefasst, was in der Sekundärliteratur über Württemberg schon berichtet worden ist. Besonderes Augenmerk legte der Autor auf die Darstellung der verschiedenen Rechtsgrundlagen von der Gründung der Anstalt im Jahr 1773 bis zur Brandversicherungsordnung von 1853, in der schlussendlich die Mitversicherung aller beim Betrieb einer Fabrik „in Bewegung versetzten Maschinen“ geklärt war. Hiermit war der Streit über das „laufende Geschirr“ beendet.The applicable insurance law is not exactly in the center academically tended law. Especially the history of insurance law is marginal. That is not understandable because of the social and economic importance of insurance in the centuries following its emergence. Therefore, the author considers it worthwhile to make documents from the Stuttgart State Archives known to the scientific community. The documents describe the problem of demarcation between public and private real estate furniture insurance. This dispute has exemplary significance for the wide coverage of various insurances, the price-calculation and the phenomenon of risk exclusions in insurance law in general. The author wants to describe, how the state - not necessarily limited to the time of cameralism - fulfills its tasks through participation in trade and commerce. The author puts special attention on the presentation of different legal bases of the founding of the Institute in 1773 to Fire Insurance Code of 1853, in which ultimately the co-insurance of all machines in a factory, that are set in motion, was clarified. This was the end of the dispute over the "current harness"

Transport Phänomene in Bi2_2Se3_3 und verwandten Materialien

One of the most significant technological advances in history was driven by the utilization of a new material class: semiconductors. Its most important application being the transistor, which is indispensable in our everyday life. The technological advance in the semiconductor industry, however, is about to slow down. Making transistors ever smaller to increase the performance and trying to reduce and deal with the dissipative heat will soon reach the limits dictated by quantum mechanics with Moore himself, predicting the death of his famous law in the next decade. A possible successor for semiconductor transistors is the recently discovered material class of topological insulators. A material which in its bulk is insulating but has topological protected metallic surface states or edge states at its boundary. Their electrical transport characteristics include forbidden backscattering and spin-momentum-locking with the spin of the electron being perpendicular to its momentum. Topological insulators therefore offer an opportunity for high performance devices with low dissipation, and applications in spintronic where data is stored and processed at the same point. The topological insulator Bi$_2$Se$_3$ and related compounds offer relatively high energy band gaps and a rather simple band structure with a single dirac cone at the gamma point of the Brillouin zone. These characteritics make them ideal candidates to study the topological surface state in electrical transport experiments and explore its physics.Einer der wichtigsten technologischen Fortschritte der Geschichte wurde von der Nutzung einer neuen Materialklasse getrieben: Halbleitern. Ihre wichtigste Anwendung ist der Transistor, welcher unverzichtbar für unseren Alltag geworden ist. Allerdings ist der technologische Fortschritt in der Halbleiterindustrie dabei sich zu verlangsamen. Versuche die Transistoren immer kleiner zu machen und die Abwärme zu regulieren und zu reduzieren werden bald ihr, durch die Quantenmechanik vorgeschriebenes, Ende erreichen. Moore selbst hat schon das Ende seines berühmten Gesetzes für das nächste Jahrzehnt vorhergesagt. Ein möglicher Nachfolger für Halbleitertransistoren ist die kürzlich entdeckte Materialklasse der topologischen Isolatoren. Ein Material, dass in seinem Volumen isolierend ist, aber an seinen Grenzen durch die Topologie geschützte metallische Oberflächenzustände oder Randkanäle hat. Deren elektrischen Transporteigenschaften umfassen unterdrückte Rückstreuung und Spin-Impuls-Kopplung, wobei der Spin des Elektrons senkrecht zu seinem Impuls ist. Topologische Isolatoren bieten daher die Möglichkeit für hochleistungsfähige Bauteile mit niedrigem Widerstand und für Anwendungen in der Spintronik, in der Daten an der gleichen Stelle gespeichert und prozessiert werden. Der topologische Isolator Bi$_2$Se$_3$ und verwandte Materialien weisen eine relativ hohe Energielücke und eine eher einfache Bandstruktur mit einem einzigen Dirac-Kegel am Gammapunkt der Brilloiun Zone auf. Diese Eigenschaften machen sie zu idealen Kandidaten um den topologischen Oberflächenzustand in elektrischen Transportexperimenten zu untersuchen und seine neue Physik zu entdecken